Dhruv Khullar: The doctor has stories

我是艾伦·阿尔达，欢迎收听《清晰生动的对话：关于连接与沟通》。

I'm Alan Alda, and this is Clear and Vivid Conversations About Connecting and Communicating.

去年我接诊过一位病人。

Last year, was seeing a patient.

他是个中年男性。

He was this middle aged guy.

他开始感觉特别疲惫。

He was starting to feel tired.

他有个朋友向他推荐了一种保健品，他还注意到，这款产品被一位知名政界人士在社交媒体上推荐过。

One of his friends told him about a supplement, and he noticed that that supplement had been endorsed by a prominent political figure on social media.

于是他下单买了，开始服用。

So he ordered it and he started taking it.

结果这产品出了副作用，他就去问ChatGPT，想弄明白是怎么回事。

Because that ended up having a side effect and that, he turned to chat GBT to try to understand.

他的腿肿了。

His leg was swollen.

ChatGPT告诉他，那是血栓。

The, chat GBT told him that it was a blood clot.

他这才来急诊室就诊。

And that's when he came into the emergency room.

我就是那时候见到他的。

That's when I met him.

我给他做了超声检查，结果还真是血栓。

And I did an ultrasound and lo and behold, it was a blood clot.

整个过程发生的时候，他根本还没看过医生。

Basically, this whole thing happened before, you know, he ever saw a doctor.

这正是当前正在发生的极端案例。

That's the kind of extreme example of what's happening.

这件事清楚地表明，传统医疗方式正在发生巨大变化，医生们必须找到办法跟上这种转变。

But it really crystallizes this idea that the traditional practice of medicine is really changing and doctors need to find a way to keep up with this transformation.

这是在威尔康奈尔医学院行医的德鲁夫·库拉尔。

That's Dhruv Khullar, a practicing physician at Weill Cornell Medical College.

他还能抽空为《纽约客》撰写关于医学实践及其在人工智能时代如何演变的深刻文章。

He also finds time to write insightful articles for The New Yorker about the practice of medicine and how it's evolving in the age of AI.

他还善于用故事的方式，把原本枯燥的解释变得清晰又生动。

He also uses stories as a way of making what might otherwise be dry explanation become clear and vivid.

在我们这档节目里聊过的所有话题中，我觉得和医生或整个医疗系统沟通，可能是每个人都得面对、并需要提升的一件事。

Of all the conversations we've had on this show, I think communicating with your doctor or with the entire health care system is something probably every one of us has to think about and get better at.

我想，你几乎把全部精力都投入到了这方面。

And you've devoted yourself, I think, pretty much to that.

你是怎么开始走上这条路的？

How did you begin that?

毕竟，作为医生，你本来并不会自然而然地去写关于医疗问题的文章。

Because as a physician, you don't naturally gravitate to writing about healthcare issues you have.

你是怎么开始的？

How did that begin for you?

其实呢，我从小就生活在医学环境中。

Well, know, I've always been around medicine.

我父亲是一名医生。

My father, is a doctor.

所以从小我就生活在医疗环境里。

And so growing up, I was around medicine.

我看到他怎么和病人相处，回家后讲的那些故事，还有他如何走进别人的生活。

I saw the way that he interacted with patients and the stories that he had when he came home and the way that he was able to enter people's lives.

随着年纪增长，我就知道这正是我想做的事。

And so as I got older, knew that's what I wanted to do.

我想当一名医生。

I wanted to be a doctor.

父母是医生，确实会增加你投身医学领域的可能性，而且这个影响还挺大的。

Having a parent who is a doctor is a risk factor for going into medicine, a pretty strong one.

所以我早早就知道，我会走这条路。

And so I knew that that would be the kind of thing that I would do.

但我对医学背后的种种因素特别感兴趣——无论是经济、政治还是社会力量，它们如何影响医疗实践和患者的照护。

But I was very interested in all the factors around medicine, all the forces, whether they're economic or political or social, that shape the way that medicine is practiced and the care that patients receive.

所以我在大学和研究生期间，这成了我特别关注的方向。

And so as I was in college and in graduate school, it really became a focus of mine.

首先，我想弄清楚到底发生了什么，为什么有些人对医疗系统体验很好，而另一些人却感到特别沮丧。

Number one, understanding what was going on and why it was that people either had good experiences or were alternatively very frustrated with the experiences they had in the medical system.

同时，我也想把这些问题传达给更多人，因为作为医生，我们对人们的处境有着独特的洞察。

But also, being able to communicate that to people because as physicians, I think we have a very unique vantage point into people's lives, into what they're going through.

而且，我们正好处在能够推动系统改进的独特位置上。

And, we're in a unique position to help improve the system.

你的文章经常刊登在《纽约客》上。

And your articles appear frequently in The New Yorker.

一个医生是怎么进入《纽约客》的？

How did a physician get into The New Yorker?

说实话，我很幸运，能走在那些大师的足迹后面。

Well, you know, I have the good fortune of following in the footsteps of of giants, really.

我一直特别欣赏奥利弗·萨克斯、阿图尔·加万德和悉达多·穆克吉他们的作品。

I mean, I have long loved the work of people like Oliver Sacks and Atul Gawande and Siddhartha Mukherjee.

他们真的给了我很大的启发。

And so they were really inspirations to me.

我希望能成为像他们那样的人。

I wanted to, be someone who did what they did.

我的意思是，既能投身临床、接触病人，深入理解他们的生活和整个医疗体系，又能用引人入胜的方式表达出来，让那些关心医疗但不懂医学体系的人，明白为什么系统会是现在这样，以及我们该如何让它变得更好。

And by which I mean, was able to engage in the practice of medicine, see patients, understand, their lives and the system deeply, and then communicate that in a compelling way so that people who, you know, were interested in health care, but maybe not expert in the medical system, could understand why the system was structured in the way it was and and how we could make a better system.

你是怎么意识到故事在医疗实践中如此重要的？

How did you come upon the idea of the importance of story in practicing medicine?

这个想法是来自你父亲是医生的家庭背景吗？

Was that something that came to you through your family connection to your father being a doctor?

是你自己慢慢发现的吗？

Did you come upon it yourself?

你是怎么走到这一步的？

How did you get there?

嗯，有一部分是受我父亲影响，但更重要的是，我意识到医学本质上就是收集故事和讲述故事的过程。

Well, was, you know, partly my father, but it was also this recognition that everything we do in medicine is story gathering and storytelling, really.

说到底，行医最根本的事，就是了解一个人身上发生了什么。

I mean, the very fundamental aspect of practicing medicine is gathering information about what has happened to a person.

有时候他们讲得并不按时间顺序，甚至可能没提到对诊断或治疗最关键的那些细节。

And sometimes they're not telling it necessarily in the most linear way, or maybe they're not emphasizing the facts that are most relevant to the diagnosis or the treatment of disease.

作为好医生，你的任务之一是让病人感到安心，引导他们说出可能有助于确诊或治疗的信息，同时让他们对你要推荐的治疗方案感到放心。

A part of your job, as a good doctor is making people comfortable in that situation, eliciting, information that, might help crack the case or aid in their treatment in some way, making them comfortable in the the treatments that you're going to recommend.

这一切，某种程度上真是一门艺术。

And all that is kind of a an art in a way.

你要收集故事里的每一个细节，然后在心里把它们拼成一个合理的整体，这样才能真正帮到病人，也能跟同事清楚地讲清楚情况。

And it's trying to gather the details of the story, but then also put it together in your own mind in a way that that makes sense so that you can, you know, help the patient, but also to tell it to your colleagues.

因为现在医学很少再靠一个人单打独斗了。

Because often, medicine is now practiced not as a lone practitioner somewhere.

跟过去相比，现在的医疗明显更依赖团队合作。

It's obviously, much more team based than it was in the past.

所以我觉得，这项能力变得越来越重要。

And so I think it's an increasingly important skill.

接下来，我觉得我们现在还必须做第三件事，那就是公众沟通。

And then if I could, you know, a third part of what we need to be doing now is is public communication.

医疗健康在社会中占据着如此重要的地位。

You know, healthcare, is such a dominant part of society.

在很多情况下，它也是一个极具争议的话题。

It's such a controversial topic in in many cases as well.

现在人们获取医疗信息的渠道太多了，无论是谷歌、人工智能还是社交媒体，因此，学会用引人入胜的方式把事实讲清楚，传递给公众，我认为是我们必须重视的第三个关键方面。

And there are so many different ways in which people now access medical information, whether it's Google or AI or social media, is that being able to tell a compelling story and, put the facts together for people in the public domain, I think is a third really important facet of what we need to be doing.

你曾在《纽约客》上写过的一篇文章，让我深刻体会到，故事是如何帮助我们更深入地理解当今医学的现状的。

A story that you tell in one of your pieces in The New Yorker really brought home to me how you can use story, how you have used story to get a deeper understanding of where we are in medicine today.

我想起你讲的那个男人的故事，他来找你之前，根本没看过医生。

I'm thinking of the story of the man whose medical history before he got to you didn't include doctors.

是的。

Yeah.

这个故事让我重新思考了我多年来一直在琢磨的一件事。

This story really brought home something that I've been thinking about for a number of years.

感觉过去二三十年，甚至整个世纪以来，我们行医的很多方式都已经变了，不再像以前那样了。

It just feels like many aspects of how we practice medicine twenty or thirty years ago, certainly in the last, century, have fallen away, have changed.

我的意思是，过去医学在几个关键领域拥有绝对的权威。

And by that I mean, in the past, medicine really had a monopoly over a few different forms of authority.

首先是权威性——人们默认医生是了解自己健康状况的唯一可靠来源。

One was, you know, legitimacy as the primary source of, you know, how you're going to understand your health.

其次，是信息和医疗知识的掌控权。

Number two was communication or information, medical information.

那时候，能获取的医疗信息非常有限。

There weren't a lot of sources of medical information.

第三，就是获得医疗服务的渠道。

And then three was just the the access to care.

你必须亲自去看医生，才能拿到药、接受检查，或者弄明白自己的身体出了什么问题。

You know, you had to go to a doctor in order to get medicine, to, get seen and understand something about your health.

但现在，这些方面都发生了根本性的变化。

And now all those things have kind of changed in a really substantial ways.

你想啊，以前是‘谷歌医生’，现在是人工智能，很多人都转向聊天机器人寻求医疗建议了。

If you think about, you know, doctor Google first and now AI, people are turning to chatbots for medical information.

再看看这些直接面向消费者的公司，你根本不用走传统医疗体系，就能买到药、获得医疗建议。

If you think about a lot of these direct to consumer companies, you know, that you can you can access medication and medical advice, really outside of the traditional medical system.

而且，随着时间推移，医疗权威的格局已经彻底变了，现在人们看待健康、寻求信息、选择信任的对象，都有了不同的渠道和圈子。

And then of course, medical authority has really shifted over time, such that there are now different spheres of influence when you think about how people are thinking about their own health and what they're going to turn to and what they're going to trust.

这件事真的让我感触很深。

And this came came home.

去年我接诊过一个病人，我在文章里叫他吉姆。

You know, last year I was seeing a patient, you know, I called him Jim in this piece.

他整个求医过程，居然一次都没去过医院。

And really, you know, he had gone through this entire medical odyssey without ever seeing a doctor.

他是个中年人。

You know, he was this middle aged guy.

他开始觉得特别疲惫。

He was starting to feel tired.

他有个朋友告诉他一种保健品，他还发现这产品被一位知名政治人物在社交媒体上推荐过。

One of his friends told him about a supplement, and he noticed that that supplement had been endorsed by a prominent political figure on social media.

于是他下单买了，开始服用。

So he ordered it and he started taking it.

结果出现了副作用，他就去问ChatGPT，想弄清楚是怎么回事。

That ended up having a side effect, and that, he turned to chat GBT to try to understand.

他的腿肿得厉害，ChatGPT告诉他，这是血栓。

His leg was full and the, chat GBT told him that it was a blood clot.

直到这时候，他才去了急诊室。

And that's when he came into the emergency room.

我就是那时候见到他的。

That's when I met him.

我给他做了超声检查，结果真的发现是血栓。

And I did an ultrasound and, lo and behold, it was a blood clot.

整个过程，他压根儿还没看过医生。

Basically, this whole thing happened before, you know, he ever saw a doctor.

你知道吗，他是通过朋友口口相传才知道这个补品的。

You know, word-of-mouth was how he got the the supplement.

他在网上下单买的。

He ordered it online.

社交媒体让这个补品显得可信，结果AI还帮他诊断出了血栓。

Social media lent credibility to taking the supplement, and then AI diagnosed his blood clot.

这只是一个极端的例子，但反映了当下正在发生的事。

And that's an extreme example of what's happening.

这清楚地表明，传统的医疗方式正在发生巨大变化，医生们必须找到办法跟上这种转变。

But it really crystallizes this idea that the traditional practice of medicine is really changing, and doctors need to find a way to keep up with this transformation.

你有一句话说得特别到位：医生的角色正在永久改变。

So a striking quote from you is that the role of doctors is changing forever.

是的。

Yeah.

这和你之前说的完全一致吗？

Is that really in line with what you've been saying?

因为关于医疗的信息和建议现在正以前所未有的方式大量涌来。

Because the delivery of information and advice about medicine is flooding us in a way it never has before.

确实如此。

It is.

我的意思是，就像我之前说的，权威、信息获取和医疗信息的可及性，这些都在发生变化。

I mean, think, you know, as I mentioned, if you think about authority, information, and access to, medical information, all those things are changing.

我觉得我们不可能再回到二十世纪那种医疗模式了，那时候人们对自己的健康几乎一无所知。

I don't see us going back to a twentieth century model of medicine where, you know, people didn't have a lot of information about their health.

人们要想获得医疗服务，只能去医院或诊所看医生。

The only way that they get, health care is by visiting a doctor or by visiting a clinic.

现在的人们越来越不愿意盲目听从医生的吩咐了。

And I think, people, don't have, you know, aren't as willing to follow quote unquote the doctor's orders anymore.

那种医生说了算的权威和可信度，我觉得已经过时了。

You know, that type of authority or legitimacy, I think is a thing of the past.

我觉得我们需要找到新的替代方式。

And I think what needs to replace it.

我觉得这个播客之所以这么重要，是因为医生的观点、我们的推理、沟通和说服方式，这些才是推动我们前进、保护人们健康的关键。

And I think why this podcast is so important is because, you know, things like the doctor's perspective or our rationale or communication or persuasion, those are the things that I think are going to help, you know, move us forward and protect people's health.

我们不能只说‘这是对的’，还得让别人明白，得好好沟通，得说服他们。

We need to not just say that this is the right thing to do, but we have to show people, have to communicate, we have to persuade them.

这其中一部分，是要靠事实和数据来说服人。

And some of that is appealing to certain sets of facts and data.

另一部分，则是讲好故事。

And some of that is effective storytelling.

还有一部分，是要明白人们做决定的原因五花八门，不一定是冷静分析过数据之后才做的。

And some of that is understanding that people make decisions for all sorts of reasons that aren't carefully weighing the data.

人们做决定，是因为他们想搞清楚这个世界，或者自己的健康状况。

People make decisions because they want to understand something about the world or their health.

他们希望在生活中拥有归属感。

They want to have a community in their lives.

他们希望对自己的身体有掌控感。

They want to have control over their body.

所以我们常常回到这种科学式的沟通方式，这确实很重要。

So I think we often fall back on this kind of scientific way of communicating, which is important.

它是解决方案的一部分，但我们也得站在对方的角度去理解他们。

It's part of the solution, but we also need to meet people where they are.

这其中一部分是要提升沟通的技巧，多加练习，认真倾听别人，找到更打动人的表达方式。

And part of that is getting better at the art of communication, practicing it, hearing people out, and finding a way to be more compelling in the way that we talk about things.

医学领域一个重大变化就是人工智能的角色，以及它带来的风险，当然还有它可能带来的好处。

So one of the big changes in medicine is the role of AI and the dangers of AI, not to mention the good AI will probably do.

Eric Topol 来过节目，谈过人工智能带来的巨大进步。

Eric Topo was on the show and talked about great advances through AI.

就在最近，他也谈到了人工智能的风险。

And just recently, he's talked about the dangers of it as well.

没错。

Right.

你觉得这两方面怎么平衡？

How do you feel it balances out?

我们目前实际享受到的好处，和潜在的风险相比，到底怎么样？

What's the good we can expect or we're already having, counted with the dangers?

我非常乐观，认为人工智能一定会以可衡量的方式改善医疗保健。

Well, I'm very optimistic that AI is going to improve health care in measurable ways.

有各种各样的原因让这成为可能，而且实际上已经有不少例子开始出现了。

And there's all sorts of reasons that that might happen and all sorts of ways it's already starting to happen.

这并不是说一切都只会是好的一面。

That's not to say it's all going to be good.

我们确实需要警惕一些风险，这样才能充分利用这些技术，同时避免陷入太多负面问题。

There are certainly things that we need to guard against to make the most of these technologies without, you know, experiencing a lot of the downsides.

不过你知道，人工智能这个话题本身太宽泛了。

But, you know, AI can sometimes be such a broad topic.

所以我喜欢从几个具体方面来看，它现在如何融入医疗体系，以及未来可能如何融入。

So I like to break it down in a few ways that it's already integrating into the healthcare system and that it might.

首先是行政和监管负担的问题。

So the first is just administrative and regulatory burden.

医生和其他医护人员要处理大量文书、账单和预先授权工作，这些都占用了他们做医疗最核心事务的时间，这其实大家都知道。

So it's no secret that doctors, other clinicians face a lot of documentation, billing work, prior authorizations, all these types of things that take away from what's most meaningful about practicing medicine.

我认为人工智能在提升这一领域的效率方面潜力巨大。

And I think AI has a lot of potential to make care more efficient in that domain.

现在已经有AI助手了，医生们说，他们能更多地与病人进行眼神交流。

We're already seeing things like AI scribes, where doctors, say that they're able to, you know, look their patients in the eye more.

他们不用再一直对着电脑打字记录整个问诊过程，反而能更有效地与病人互动。

They're not, you know, sitting at the computer and having to type the entire visit, but they're actually able to engage the patient in a much more effective way.

这部分属于行政事务的优化。

So part of this is administrative.

我还想特别强调另一个方面，就是患者导诊。

I think the other area that I would really emphasize is patient navigation.

作为医护人员，有时候我们容易忘记，对普通人来说，医疗系统有多让人困惑。

Sometimes as clinicians, it can be hard to remember how bewildering the medical system can be.

你根本不知道一次就诊到底要花多少钱。

You have no idea how much you're going to pay for a visit.

要顺利地在医疗系统里预约到合适的时间，真的挺难的。

It can be hard to go through the medical system, get the right appointments at the right times.

这类事情，我觉得AI都能帮上忙。

All these types of things, I think AI can help with.

不仅如此，医生和患者之间的互动也能得到改善。

And not only that, but the actual doctor patient interaction.

我接触过一些患者，他们干脆直接问能不能录下就诊过程。

So I've talked to patients who basically ask if they can record the visit.

录完之后，他们会把录音上传到AI模型里。

Then they upload it into an AI model.

然后跟AI复盘一下就诊时发生了什么。

And then they talk to the AI about what happened during that visit.

比如确诊了心力衰竭或者糖尿病，他们就能不停地跟聊天机器人追问：这到底意味着什么？会对生活造成哪些影响？这种事，再尽职的医生也不可能24小时陪着聊。

So that, let's say they get a diagnosis of a heart failure or diabetes, they can endlessly talk to the chatbot about what that means and how it might affect their lives in a way that even the most well meaning clinicians can spend twenty fourseven talking to someone like that.

我还真没想过这一点。

I hadn't thought of that.

那会不会出现一味迎合或者编造信息的风险呢？

And there there isn't a danger of sycophancy or hallucination?

确实，这种风险是存在的。

Well, so that is a danger.

我觉得把它当作辅助工具还是很有帮助的。

I think that can be very helpful as supplements.

比如说，在你和一位受过专业训练的医生建立关系、共同应对这些问题的前提下，AI可以成为一个非常有用的补充——你可以跟它复盘就诊时的细节，更深入地理解那些内容。

So, you know, in the context of having a relationship with a clinician who's trained and going through these things with you, it can be a really helpful adjunct because you can talk to the AI about, you know, what has happened during that encounter and and, you know, understand it at a deeper level.

不过你说得对，我再举个例子。

But, you know, to your point, I'll give you another example.

我认识一位女士，她替母亲这么做，想弄清楚医院里到底发生了什么。

You know, I I spoke with a woman who did this kind of for for her mother and tried to understand what was happening in the hospital.

结果时间一长，这个AI开始把她母亲的病情和自己的病情搞混了。

And over time, the AI started to confuse her mother's medical conditions with her own medical conditions.

天哪。

Oh my god.

是的。

Yeah.

所以这就是可能发生的风险。

So this is the this is the type of risk that can happen.

我想强调的是，这可以作为辅助手段，但目前还不适合作为人们获取或接受医疗照护的主要方式。

So, you know, I I do want to emphasize that this is something that can be, an adjunct, but I think not yet ready to be a primary way that people, access care or go through their care.

不过，我对一些领域非常乐观，比如药物研发。

And and then there, you know, there are things that I'm very optimistic about, like drug discovery.

我认为人工智能在探索化学空间、设计新分子、理解药物靶点，以及协助医生和其他临床人员进行诊断方面会非常有帮助。

I think, AI will be very helpful, for, you know, scouring chemical spaces, designing new molecules, understanding drug targets, and then helping doctors and other clinicians with diagnosis.

即使是最优秀的医生，人的大脑能记住的信息也是有限的。

You know, there's only so much that people can hold in their mind, even the best clinicians.

而这些大语言模型能够从病历中捕捉到可能对诊断有帮助的重要细节。

And these LLMs can pick up important details in a medical chart that might be helpful for the diagnosis.

所以，这些才是我认为真正有效的应用。

So those are the types of things that I think are really effective.

我想提一下几件让我很担忧的事。

I do want to mention a few things that I'm pretty concerned about.

其中之一是把决策权完全交给这些模型。

One is this idea of turning over our agency to these models.

正如你所说，它们依然会出错，有时候甚至错得很严重。

We know, as you mentioned, they're still fallible, in some cases very much so.

我认为，无论是医生还是患者，最终的医疗决定都应该是人来做，而不是电脑，一方面是因为这些模型会犯错、会幻觉，另一方面是因为我们人类能带来一些模型里未必有的视角和价值观。

And I think that clinicians and patients, we should be the final arbiters of care, not computers, in part because the mistakes and hallucinations, but in part because, we may bring a very different set of perspectives and values to the clinical setting that aren't, necessarily present, in these models.

另一个让我特别担心的问题，是我平时带住院医师和医学生时看到的——认知能力的退化。

The other big thing I'm concerned about as someone who works sometimes with residents and medical students is this idea of cognitive descaling.

如果你把大量关键思考的工作都交给AI，这在所有知识型工作中都是个问题，但在医学领域尤其危险。

If you're handing over a lot of your critical thinking to an AI, this is a problem in all, I think, knowledge work, but particularly challenging in medicine.

那是不是意味着，你再也学不会自己分析病情了？

Does that mean that you don't acquire the skills to think through a medical case yourself?

最后我想说的，是一种哲学层面的忧虑：这项技术实在太强大了。

And the last thing I'll mention is is kind of a philosophical worry, but this technology is so powerful.

而且人们很容易觉得，这种技术能解决我们所有的问题。

And it's so there's such a temptation to think that it can solve all our problems.

但很多问题其实并不是靠技术就能解决的。

But a lot of our problems are not necessarily amenable to technology.

它们可能是政治问题、经济问题，或者社会问题。

They might be political problems or economic problems or social problems.

我觉得，哪怕技术再强大，一味认为它能帮我们解决所有问题，这其实很危险。

And I think there's a real danger in just thinking that, we can use technology to work our way out of every problem, even if it's a very powerful technology.

你说与其过分关注AI能做什么，医生更应该记住，他们得回归到治愈的本质。

You say that rather than getting too caught up in powerful things that AI can do, that doctors should keep in mind that they need to return to healing.

对。

Mhmm.

你所说的‘治愈’，具体指的是什么？

What what do you mean by healing?

这和我们目前的发展方向有什么不同？

How how does that differ from the direction we may be headed in?

是的。

Yeah.

我觉得，AI会越来越擅长处理医学中的许多技术性工作。

Well, I think, you know, AI will be increasingly effective at doing a lot of the technical aspects of medicine.

但还是有很多护理环节，患者希望由医生和人类来完成。

But I think there are still many aspects of care that people will want physicians and human doctors to do.

我们做的很多事，其实都需要细腻的沟通和同理心。

And there's a lot of things that, you know, we do that really require delicate communication and empathy.

所以我觉得，就算有了非常高效的AI模型，医生在应对不确定性方面，依然非常重要。

So I think, you know, even if we have a very effective AI model, let's say, I I think a doctor still can be very important for things like managing uncertainty.

你懂的。

You know?

是的。

Yeah.

每个诊断、很多治疗方案，都存在一定程度的不确定性，而人们还是希望有人类能帮他们一起面对和处理这些不确定。

Every diagnosis, many treatments, they still have a level of uncertainty that I think people will want other humans to help them manage and and work through.

比如，了解一个人真正看重什么。

I think things like eliciting people's values.

当你身患重病、生命垂危，或者要为孩子做决定时，什么对你来说最重要？

You know, what's important to you when you have a serious illness or when you're at the end of life or when you're making a decision about your child.

挖掘患者的价值观和偏好，再把它们和当前最可靠的医学证据结合起来，这依然是医生工作中非常关键的部分。

Eliciting people's values, preferences, integrating those values with what's known from the best available science, that is gonna continue to be a really important part of what doctors do.

而且我觉得，我们希望有人能为我们的治疗全程负责。

And then I think, you know, we want someone to take responsibility for your care.

我们希望有个人能站出来，说：我觉得这个选择最适合你。

We want a human to be the one that's saying, you know, I think this is right for you.

这是我们共同决定要走的路。

This is the decision that, you know, we're gonna arrive at together.

我不觉得人们愿意让那些最高风险的决定，交给一个冷冰冰的算法来做，或者让它来承担责任。

And I don't think people want necessarily for the highest stakes decisions in their lives, some impersonal algorithm that's making that decision or taking responsibility.

他们更希望由一个真实的人来承担这个责任。

I think they want a person who's going to end up doing that.

最后我想说的是，这些模型在某些领域确实非常有效，甚至令人印象深刻。

And the last thing I'll I'll say is that these models can be extremely effective and, impressive in certain domains.

但它们往往具备一种‘参差不齐’的智能。

But they often have what's called jagged intelligence.

也就是说，它们可能在某一项或几项具体任务上表现得特别出色。

So they might be very effective at doing one particular thing or several particular things.

但人类的智能是全面的。

But humans have rounded intelligence.

我们擅长很多不同的事情，能从更广的视角看问题，也能理解事情背后的来龙去脉。

You know, we are good at many different things and we can see in the broader context and we can understand what's happening.

所以我觉得，这再次说明了为什么短期内医生不太可能被取代——我希望看到的，是医生能高效地借助人工智能，来提升医疗质量。

And so I think, again, it just gets back to this idea that, it's a reason that I don't think we're gonna see a lot of displacement in the near term, of doctors, but it's going to be, my hope is an augmented situation where doctors use AI very effectively to improve the quality of care.

广告休息回来后，德鲁夫·库拉尔会更深入地探讨一个观点：人工智能虽然确实能帮助医生诊断病情，却永远无法取代医生的人性化陪伴。

When we come back from our break, Dhruv Khullar digs deeper into the idea that AI, though certainly useful in helping a doctor diagnose a patient's problems, will never replace the doctor's human presence.

顺便提醒一下，Clear plus Vivid 是非营利项目，所有盈余资金都将捐给石溪大学的科学传播中心。

Just a reminder that Clear plus Vivid is nonprofit, with everything after expenses going to the Center for Communicating Science at Stony Brook University.

这个节目和中心都致力于改善我们彼此之间各种影响生活的连接方式。

Both the show and the center are dedicated to improving the way we connect with each other in all the ways that influence our lives.

你可以通过成为 Clear and Vivid 的赞助会员来提供支持，访问 patreon.com。

You can help by becoming a patron of Clear and Vivid at patreon.com.

在最高档位，你可以每月参加我和其他赞助会员的线上聊天，我还会为你录制一段语音留言。

At the highest tier, you can join a monthly chat with me and other patrons, and I'll even record a voicemail message for you.

要么是一段得体礼貌的留言，说明你暂时不方便接电话；要么是带点调侃的版本，说我此刻根本不想跟任何人说话。

Either a polite dignified message from me explaining your inability to come to the phone or a slightly snarky one where I explain you have no interest in talking with anyone at the moment.

我很高兴地告诉大家，那个带点调侃的版本要受欢迎得多。

I'm I'm happy to report that the snarky one is by far more popular.

如果你想继续参与关于连接与沟通的讨论，欢迎加入我们，访问 patreon.com/clearandvivid。

If you'd like to help keep the conversation going about connecting and communicating, join us at patreon.com/clearandvivid.

patreon.com/clearandvivid。

Patreon.com/clearandvivid.

谢谢大家。

And thank you.

这里是《清晰而生动》。

This is Clear and Vivid.

现在继续我和德鲁夫·库拉尔的对话，聊聊在人工智能时代，医生的角色如何变化，却依然不可或缺。

And now back to my conversation with Dhruv Khullar and how the doctor's role becomes different, but still crucial in the age of AI.

现在大家都觉得人工智能什么都能做，那医生到底还缺不缺呢？

In this moment where people think AI can do everything, you know, what is it that doctors are needed for?

医生未来还会有哪些不可替代的作用？

What will they be needed for?

我听过一个故事，一个我采访过的女性，我叫她玛格丽特吧。

And I heard this story, this woman I I I talked to, I'll call her Margaret.

她告诉我，自己长期与酒精作斗争。

She told me how she had struggled with alcohol for a long time.

她一直想戒酒，但年纪越来越大，六十多岁了，还是控制不住地过量饮酒，生活已经明显受影响。

She always wanted to quit alcohol, but she, you know, as she get older, she was in her sixties, and she continued to to drink in excess in a way that was really starting to affect her life.

她的主治医生直接指出了这个问题。

And her primary care doctor called her out on it.

回想我们之前聊过的奉承问题，AI模型常常只是顺着你说，努力让你感觉良好。

Thinking back about our conversation about sycophancy, where AI models often just kind of go with whatever you're saying and try to make you feel good about it.

她的主治医生却采取了完全相反的做法，直接告诉她，这确实是个严重问题。

Her primary care doctor took the opposite tack and and told her that this is a real problem.

而且情况还在变得更糟。

It's getting to be a worse problem.

于是医生当面指出了她的问题。

And so she called called Margaret out on it.

玛格丽特决定干脆彻底戒酒，结果马上出现了戒断反应——焦虑、颤抖，全都来了。

And Margaret decided to, you know, just stop drinking basically cold turkey and she started experiencing symptoms of alcohol withdrawal, anxiety, tremors.

她的心跳得特别快。

Her heart was racing.

她通过医疗平台给医生发了消息，医生立刻回复了。

And she messaged her doctor on the portal and the doctor responded immediately.

医生告诉她，自己会一直陪着她，如果她真的担心，随时可以去急诊，医生会亲自在急诊室等她，陪她度过整个过程。

And she said that she's there for her and that if she wanted to come to the emergency room, if she was that concerned, the doctor would meet Margaret in the emergency room and walk her through the whole experience.

最后，玛格丽特决定待在家里，但整个晚上她都在通过平台给医生发消息。

And ultimately, Margaret decided to stay home, but she messaged her doctor throughout the evening.

医生一直陪着她。

The doctor was there for her.

她现在把戒酒成功、人生状态达到几十年来最好的水平，全都归功于这位医生。

And and she now credits that doctor with being sober and being in the best place in her life, in decades because of this physician.

这位医生在最关键的时候出现了。

Her doctor, you know, showed up when it mattered.

她陪着玛格丽特度过了最艰难的时刻。

She walked her through the most difficult moments.

当她觉得玛格丽特该换种方式做事时，她直接指了出来。

She called her out when she felt like she needed to be doing something differently.

我觉得，即使在人工智能越来越强大的今天，医生依然能提供这样的支持。

And those are the types of things I think doctors still have to offer, even in a world where AI becomes increasingly potent.

你提到过，决策权现在掌握在机器手里，这个问题。

You talked about the problem of decision making being in the hands of a machine.

现在这种情况普遍吗？

How common is that now?

以后会成为问题吗？

Is it going to become a problem?

现在是不是已经是个问题了？

Is it already a problem?

比如，要不要做手术，或者什么时候该停止常规体检，这些决定该由谁来做？

Is decision making whether you should have a medical procedure or not, or when to stop doing your routine checkups?

这个问题其实特别有意思，也很微妙。

Well, so this is such an interesting and and kind of nuanced question, really.

在某些情况下，我们反而希望让算法来做决定，因为医生和其他专业人士难免会有偏见。

I mean, in some cases, we may want algorithms to be making decisions because doctors, other professionals have all sorts of biases.

这一点在医疗领域很明显，在司法系统里也是如此。

And we know that's true in medicine, and we know that's true in the criminal justice system.

比如我们知道，法官一天快结束时累了，或者还没吃午饭，判罚往往会更重。

We know for instance that if you get a judge later in the day when they're tired, or before lunch, they're gonna give you a harsher sentence.

我不希望这种事在社会上发生。

And I don't think we want that type of thing happening in society.

所以我觉得AI在某些地方是可以发挥作用的。

And so there are places where I think AI may play a role.

它可能不是最终的决策者，但能为这些重要决定提供支持。

It may not be the final decider, but it may provide some support for these important decisions.

不过说到你的问题，它现在也被用在一些让我觉得相当不安的方式上。

But to your question, you know, it's also being used in ways that I think should make us quite uncomfortable.

比如去年，有一起针对大型保险公司联合健康保险的诉讼，指控他们用算法来决定患者住院后在康复中心该住多久。

Last year, for instance, there was a case, that came against, one of the big insurers, UnitedHealthcare, where the argument was that they were using an algorithm to set how long they thought that patients should stay in a rehab facility after a hospitalization.

而且很多时候，这个时限定得非常严格。

And often, that was pretty, restrictive.

即使医生认为患者可能需要住上几周甚至几个月，只要算法给出不同的意见，就会压过医生的判断。

And so even if the doctors were saying that they felt maybe a patient need to be in there for weeks or months, if the algorithm said something different, that was kind of prioritized over these clinicians.

我觉得，这类情况以后会越来越常见。

And so that's an example I think we're going to see a lot of.

我们得想清楚该怎么应对，因为人们很容易会依赖这些所谓中立的算法来做各种决定，不管是康复住院时长、医疗程序、住院天数，还是保险公司的理赔标准，等等。

And we need to figure out how to deal with because there's going to be a temptation to use these supposedly impartial algorithms to set all sorts of decisions, whether it's around rehab stays, or procedures, or length of hospitalization, or benefits at an insurance company, whatever it might be.

对于这个问题，我没有简单的答案，只能说我们在把决策权交给这些AI模型时，必须保持高度警惕。

And that's not something that I think there's an easy answer to other than to say we should be very cautious when we're turning over our agency to these AI models.

是的，说实话，现在我把自己的决策权交给政府，我也觉得不太踏实。

Yeah, I must say I'm feeling cautious about turning over my own decision making process to the government now.

MAHA运动在我看来有点危险。

The MAHA movement seems a little dangerous to me.

我的意思不是说这是个政治问题。

Mean, it's not a political decision.

真正让我担心的是自我保护的本能。

It's really self preservation that makes me wonder.

前几天我跟朋友聊到某个医疗程序，他问我：这项目通过FDA认证了吗？

I was saying to a friend the other day, we talked about some procedure and he said, has it been FDA approved?

我说，要是真通过了FDA认证，我反而更不放心了。

I said, you know, if it's been FDA approved, it makes me nervous.

是的

Yeah.

对

Yeah.

其实呢，说到MAHA这个运动，大家往往对它有完全不同的理解。

Well, you know, one of the challenges is, when we talk about MAHA, I think people often have a and people can see very different things in that movement.

它并不是一套明确统一的政策或原则。

You know, it's not a singular set of policies or principles that have been pulled out.

我觉得，像对疫苗持怀疑态度、限制接种疫苗，甚至质疑疫苗有效性，这些做法都很成问题。

You know, I think that things that are on the end of, vaccine skepticism or trying to reduce the, access to vaccines or even cast doubt on the efficacy of vaccines are very problematic.

但另一方面，像鼓励锻炼、改善饮食、减少超加工食品，这些主张大多数人其实都支持，包括大多数公共卫生专家和医生。

On the other hand, I think things that are around encouraging physical activity or improved nutrition or reduction of ultra processed foods, those are things that I think most people can get behind, including, most public health officials and physicians.

所以我希望我们能引导这个运动往更积极的方向发展，让它更贴近目前最可靠的健康科学证据，远离那些把疫苗说成危险品的极端观点。

And so what I hope is that we're able to kind of shape or nudge, that movement in a direction that's much more positive and one that aligns with the best available evidence, on what it takes to be healthy and away from some of these other more fringe ideas about vaccines and and them being dangerous.

是的

Yeah.

你能再多说说吗？

Tell me more about that.

我担心的一点是，人们对证据的信任正在下降。

Because one of the things that I feel concerned about is the lowering of confidence in evidence.

我希望这种趋势不要变成制度化的现象。

I hope that doesn't become institutionalized.

如果在疫苗这种重大问题上，大家选择忽视绝大多数证据，那就会削弱人们对任何基于证据的决策的信任——你开始怀疑，到底该相信多少证据才对。

The idea that on one big issue like vaccines, you ignore majority of evidence, it kind of lessens the ability to trust any decision making based on you wonder how much evidence.

是的。

Yeah.

谈公共卫生的时候，你面对的是大量背景各异、理解水平不同的人。

When you're talking about public health, you're talking to many people at once with many different levels of understanding.

那我们该怎么摆脱这种困境呢？

So how do we work our way out of that?

对。

Yep.

我觉得首先要说的是，科学方法的运用，以及这类证据的产生和遵循证据的指引，给社会带来了巨大的好处。

I think the first thing to point out is that the use of the scientific method and the generation of these evidence this type of evidence and then following the evidence where it leads has been such a boon to society.

我的意思是，现代医学的基础，其实就是你所说的那种理念：我们以特定的方式开展研究，客观地理解结果，然后据此研发药物、疫苗或公共卫生干预措施。

I mean, what modern medicine is based on is basically the idea that you're describing, which is, we are going to conduct research in a particular way, and understand the outcomes in an unbiased way, and produce drugs or vaccines or public health interventions based on those.

过去一个世纪，这大大提升了人类的预期寿命。

That has led to an enormous improvement in life expectancy over the past century.

所以当有人抛弃这种思维方式，或者放弃这种做科学和做事的方式时，我认为这非常反常，也非常危险，正像你所说的那样。

And so when people are discarding that type of thinking or that way of doing business and science, I think it is very perverse and very dangerous, for the reasons that you're describing.

我想指出的是，人们终将渴望一个更贴近公共卫生最佳实践和科学证据生成标准的机构体系。

I will note that, you know, I think there will be a hunger for an institution and a set of, health care agencies that align more with the best practices of public health and scientific evidence generation.

我们已经看到，比如过去一年里，公众对疾控中心或卫生与公共服务部的信任度有所下降。

We already see that, for instance, trust in what is happening in the CDC or HHS has declined over the past year.

但大多数人并不支持限制疫苗获取，也不支持传播误导性信息。

And people are by and large not enthusiastic about rolling back access to vaccines or putting out information that is misleading.

当然，美国幅员辽阔，总有人会接受这些误导性信息，并把它用在自己的生活中。

Of course, it's a big country and many people will take this information that's being put out that's misleading and apply it to their lives.

我们已经看到了这样的后果。

And we see the consequence of that.

比如麻疹疫情卷土重来，这是几十年来最严重的一次，原因就在这里。

We see things like measles outbreaks, the worst measles outbreaks that we've had in decades because of what is happening.

但我不觉得这场仗已经输了。

But I don't think that, this is a battle that's somehow lost.

人们其实看得到正在发生的事，也能感受到它的影响。

I think people see what's happening, they can see the impact of it.

我依然乐观，相信我们终能扭转局面，让公众对公共卫生的信任重新超过现在这个水平。

And I am optimistic that, we'll be able to turn the corner and get back to a place where, public health is more trusted than it is today.

我觉得在这里，我们也该谈谈近年来公共卫生沟通的失败之处。

And I think here we should talk about the failures of public health communication in recent years as well.

我们过去没做好一件事：用大白话讲清楚发生了什么，帮大家理解科学是会不断更新的，认真倾听人们的担忧，客观权衡各种公共干预措施的利弊。

We have not done a great job of speaking plainly about what is happening, helping people understand the way that science changes over time, really listening to people's concerns, weighing the costs and benefits of various, interventions in the public sphere.

所以这些方面，我觉得都有很大的改进空间。

So all these things I think are, certainly room for improvement.

但我认为这些教训已经被吸取了，现在我们需要在今后付诸实践。

But I think the lessons have been taken and now we need to apply them going forward.

你让我想起来，我们刚才一直在谈讲故事的力量，以及如何让公共卫生信息更有人情味。

You remind me, we've been talking about the efficacy of storytelling and humanizing the informative nature of public health.

我特别注意到，《急诊室的故事》这部剧对你意义重大，似乎让你更接近自己在医学领域想要达到的目标。

And I'm struck by the idea that storytelling in the television series, The Pit, has meant something to you and apparently brought you closer to where you want to be in medicine.

确实如此。

Absolutely.

我特别喜欢这部剧。

I love this show.

我觉得它最了不起的地方在于，不仅精准还原了医学的技术细节，更重要的是，真实呈现了当今行医者的情感体验。

What I think is so great about it is that it not only captures the kind of technical aspects of medicine very accurately, but more to the point, the emotional aspects of what it feels like to practice medicine today.

社会的各种挑战——不管是政治的、经济的、社会的还是文化的——最终都会渗透到急诊室和医院里。

The way that, society with all its challenges, whether they're political, economic, or social, cultural, they find their way into the emergency room in into the hospitals.

过去五到十年，我写过不少自己一直关注、觉得重要的议题。

And, you know, over the past five or ten years, I've written about a number of issues that I've, been interested in reporting on that I thought were important.

比如气候变化、医疗中的歧视、人工智能、镰状细胞病，还有照护者的巨大压力。

Things like climate change or, discrimination in health care, artificial intelligence, or sickle cell disease, and all these caregiver burden.

而《急诊室》这部剧巧妙地把这些复杂的议题，融入到短短一班次的故事里，用特别动人的叙事方式，把那些枯燥的研究数据或政策条文背后的真实声音展现了出来。

And somehow the pit incorporates all these really complex topics in a single show over a single shift in a really beautiful narrative way that gives voice to what, let's say, wonky research is showing or what this technical policy has has dictated.

观众能真正感同身受，产生共鸣。

And it comes out in a way that people can really resonate with.

我觉得这其实是一种非常重要的公共倡导——它让我们看到，今天的医疗究竟是什么样的，以及为什么它会让人有这种感受。

And I think that in a way is a really important public service announcement that this is the way that medicine is today and and here's some of the reasons that it feels like it does.

诺亚·怀尔出演过这部剧，他跟我聊过剧集背后的制作细节，最初的想法，还有它是怎么一步步发展起来的。

Noah Wiley has been on the show, and he talked with me with a view of the details behind the making of the show, what the idea was originally, how it developed.

我很高兴看到他也在为这部剧写剧本。

I'm glad to see he also writes on the show.

是的。

Yeah.

但有意思的是，他们还真给演员们安排了一整套密集的医学培训。

But it's very interesting that they gave them a shock course in medical training.

确实看得出来。

It shows.

真的能感受到。

It shows.

我再也无法把诺亚·怀利当成普通演员来看了。

I can't I really can't look at Noah Wiley anymore.

现在一看到他，就没办法把他当我的主治医生了。

Now it's not to think of him as my attending physician.

我的意思是，你知道的，他把这个角色演得太像了，让我一看到他就想起当年在医学院时那些让我害怕的带教老师。

I mean, that just you know, I I still like he he has so embodied that character for me that I I I see my medical school days and my attendings that I was scared of.

他在剧里的表现真的特别出色。

And he's he's really fantastic in the show.

是的。

Yeah.

你不妨听听那期节目，可能会觉得挺有意思。

It might be interesting for you to listen to that episode.

他在剧里演得特别棒。

He's he's very good on it.

对。

Yeah.

我会听的。

I will.

当然了。

Absolutely.

你知道吗？

You know what?

这次对话对我来说特别重要，不过我们时间差不多了。

This has been really an important conversation to me, but I think we're running out of time.

但在每期节目结束前，我们都会问七个快速问题。

But before we end every show, we do seven quick questions.

希望你的回答能帮我们更了解你这个人。

I hope your game helps us understand you better as a person.